Provider Demographics
NPI:1356394266
Name:SAMCHUK, TATYANA (PA)
Entity type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:SAMCHUK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:110 S BEDFORD RD
Mailing Address - Street 2:CAREMOUNT MEDICAL PC
Mailing Address - City:MOUNT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-3446
Mailing Address - Country:US
Mailing Address - Phone:914-241-1050
Mailing Address - Fax:914-242-1516
Practice Address - Street 1:193 W 237TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-4141
Practice Address - Country:US
Practice Address - Phone:718-303-0479
Practice Address - Fax:718-303-0480
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY008220363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02240999Medicaid
P54684Medicare UPIN
NYA400118747Medicare PIN